Neil Chheda, MD, assistant professor of otolaryngology at the University of Florida in Gainesville, realized a few years ago that nearly half of his patients on proton pump inhibitors were taking them incorrectly.
The issue of noncompliance extends to other areas of otolaryngology as well. “Patients don’t always follow through with the treatment regimen that is recommended,” Dr. Chheda said.
Continuous positive airway pressure (CPAP) compliance rates, for example, hover around 65 percent (Medical Care. 2004;42(3):200-209). Gastroesophageal reflux disease (GERD), chronic sinusitis, allergies and thyroid conditions can all be managed with medication, but chances are good that many patients are not taking their medications as ordered. In fact, over half of all Americans with a chronic disease admit to not following their physicians’ medication and lifestyle advice (American Heart Association. 2002. Statistics you need to know).
“If the patient doesn’t follow our recommendations, is it really a treatment failure, or is it a failure of the patient to follow recommended protocol?” Dr. Chheda said.
Dr. Chheda eventually found a solution to his compliance problem when he and his staff realized that those patients who received information from multiple sources were the most compliant. “Those who were being questioned by us and speech/language pathology tended to have higher compliance rates,” he said.
While Dr. Chheda relies on personal reminders to improve patient compliance, a host of communication devices, ranging from web-based medication reminder systems to “smart” pill bottle covers and electronic health record (EHR) systems with built-in reminder functions can call, text or e-mail patients. Some even report back to the physician—with the patients’ permission, of course.
Doctors, unfortunately, “know nothing about these systems,” said Brian Morris, MD, an internist and associate director of the Comprehensive Health Program at the University of California at Los Angeles (UCLA), which studies ways to help people adopt healthier behaviors. “As physicians, we tend to assume that what we tell the patient to do is what they’re doing, and that’s not always the case.”
“If the patient doesn’t follow our recommendations, is it really a treatment failure, or is it a failure of the patient to follow recommended protocols?”—Neil Chheda, MD
Automating the Process
Studies show that electronic communications can be an effective method of increasing compliance. Researchers from Brigham and Women’s Hospital, Massachusetts General Hospital and the University of California found that text message reminders substantially increase sunscreen usage (Arch Dermatol. 2009;145(11):1230-6). In addition, physicians at Mount Sinai in New York have found that text message reminders increase medication compliance and decrease organ rejection in teenage transplant patients (Digestive Disease Week 2009: Abstract 175. Available at: http://www.ddw.org/wmspage.cfm?parm1=883).
Lawrence Gordon, MD, an otolaryngologist in private practice and founder of Waiting Room Solutions, an EHR system that includes reminder functions, said many doctors underestimate the potential of electronic reminders. “Often, doctors will judge their patients’ abilities incorrectly; they’ll say, ‘My patient population would never do this,’” he said. “But some of our preconceived notions of age and socioeconomic status don’t always hold true. Some older people are very tech savvy.”
According to Richard Adler of the Institute for the Future/People & Technology, almost every household has access to an Internet-connected computer. Over 250 million Americans have cell phones. Forty-one million Americans, including many over age 40, send and receive text messages almost every day, and many of them are open to receiving treatment reminders via e-mail and text, he said.
“Patients who receive electronic reminders feel that you’re in control of the process,” Dr. Gordon said. “It really instills confidence when they see you communicating with them electronically.”
Web-Based Systems
A variety of Web-based reminder systems, including MyMedSchedule (mymedschedule.com), RememberItNow (rememberitnow.com) and Intelecare (intelecare.com), enable patients or their care providers to log on, enter their medications or treatments and schedule personalized reminders.
Greg Duggins, a 55-year-old patient from New York, uses MyMedSchedule to manage his medications. “I set it to send me a text. When I hear it, I know I got to get up and do something. The program doesn’t let me forget,” Duggins said. Duggins also shares system-generated medication reports with his physicians at each appointment.
—Jan Berger, MD
“Smart” Medication Dispensers
Technology-enhanced medication dispensers also remind patients to take their pills and create compliance reports that can be shared with health care providers. Maya from MedMinder (medminder.com) is a seven-day pillbox that can be programmed to flash, then sound an alarm, when it’s time for the patient to take his medicine. If the medication is not taken within a specified timeframe, an alert can be sent directly to a care provider. Weekly compliance reports are also available.
The Vitality GlowCap (vitality.net) is a high-tech pill bottle cover that screws onto a regular medication vial and glows, beeps or calls the patient when it’s time to take medication. Like the Maya, the GlowCap also sends weekly and monthly compliance reports. According to an internal study, GlowCap users take their medications on time over 95 percent of the time, compared to 70 percent for users of traditional pill bottles http://www.vitality.net/docs/pharma_presentation.pdf).
Integrated Electronic Health Records
While most medical practices will be using electronic health records (EHRs) in a few years, some physicians are using EHRs right now to enhance patient communication.
Andrea Kittrell, MD, an otolaryngologist in private practice in central Virginia, uses Dr. Gordon’s Waiting Room Solutions (waitingroomsolutions.com). “It helps us be more efficient in our patient management,” Dr. Kittrell said. “The automated functions help us be safer; we’re not dropping results and forgetting to call patients, so our patients are getting higher quality care.”
Waiting Room Solutions allows care providers to create recall reminders based on patients’ diagnoses and treatment plans. The program, for instance, will contact all patients diagnosed with hearing loss who have not been in for an annual audiogram, first by e-mail, then with an automated voice message. Similarly, if the physician hasn’t received results from an ordered CT scan within a specified amount of time, the system will reach out to the patient to see if the test has been scheduled.
TeleVox, a communications company, produces an electronic reminder program that works with existing EHRs. The program, HouseCalls, sends reminders via voice, text and e-mail. It can also send preventative care messages, about smoking cessation, for instance. All reminders require a response from the patient, because “we’re attempting to move people to action, and whether that’s showing for an appointment or following a treatment plan, it’s more effective to have some action for the patient to take when they receive the message,” said Corey DeGeorge, TeleVox senior director of marketing and product management.
Jan Berger, MD, chief medical officer of Silverlink Communications, sees a lot of potential for automated reminders.
“Communication is the foundation of good health,” Dr. Berger said. “Automated messaging can reach out to patients, identify barriers and relay that information to doctors. My hope is that EHRs will help doctors get the information they need in real time so they can intervene.”
Getting up to Speed
But not all reminder systems integrate easily with existing EHRs.
“The biggest problem I see right now is usability of these systems,” said Rodney Lusk, MD, Internet and information technology coordinator for the American Academy of Otolaryngology-Head and Neck Surgery. “Many of them are created, in large part, by software engineers who think they know how doctors work.”
Lack of a common electronic language also makes it difficult for certain programs to work together. Waiting Room Solutions can generate lab action reminders, but if the lab’s software doesn’t integrate with the EHR, lab results have to be scanned in manually before reminders are sent. The current medication reminder systems are designed for use by patients; physicians may get compliance reports if the patient chooses to share that information, but the reports do not automatically integrate with the EHR.
Still, Dr. Gordon says the benefits of adopting these systems outweigh the costs. Most physicians who are currently using electronic reminders to interact with their patients are on the cutting edge of technology, he said. “Most of them already have a smart phone. They understand how failure to communicate not only impacts their clinical care but also their bottom line,” Dr. Gordon said.
Dr. Kittrell adopted an EHR with built-in reminders after working in a group practice that used traditional charting and reminder methods. “As a solo practitioner, it’s important for me to have low overhead,” Dr. Kittrell said. “Having this system basically eliminates a staff member.”